AW: [HSF] Deairing the heart
Ben Bidstrup
benjamin.bidstrup at bigpond.com
Mon Mar 5 09:04:13 EST 2007
But we wear it even in those circumstances.
>Wait a minute - we are not the only ones to blame for CVA's.
>
>Though I have no claim to actual data - but how
>many times have you guys admitted a patient
>after a cath - and as a little bonus gotten a
>CVA/TIA or even a good ol' fashion dissection?
>Unfortunately, sometimes these "problems" are
>not often obvious for a couple of days after the
>procedures.......
>
>
>-michael
>
>
>
>On Mar 4, 2007, at 4:10 PM, Ben Bidstrup wrote:
>
>>To get a handle on some of these devices and
>>techniques, we must look more widely.
>>
>>
>>We cannot even guess at the incidence of
>>neuropsych damage after valve surgery. All but
>>a few of the papers have been on CABG patients.
>>So we do like many other groups, extrapolate
>>from the many CABG studies done on this. How
>>representative are these patients of the real
>>world? Look at the paper mentioned recently
>>from van Dijk in JAMA.
>>Does this include use or avoidance of
>>cardiotomy suction? How is venting handled?
>>Suck like h..l to keep the heart empty and get
>>lots of air/blood interface or
>>gently when there is blood pooled.
>>What has happened to the incidence of stroke
>>over time, perhaps the crudest marker we can
>>use? Whose data do we use? That is a question
>>a brief search was not easily answered. A
>>report from the New York database on CABG
>>reported a 1.4% incidence. In a review from
>>Johns Hopkins on AVR CABG patients (233) there
>>was an incidence of approx 14% across the
>>groups with grafts. However no longitudinal
>>information. (Kobayashi Ann Thorac Surg
>>2007;83:969-978) .
>>
>>So how do we tell the difference that CO2
>>displacement, TEE or other maneuvers make? Does
>>Embolex make a difference? TEA has commented
>>that we do all sorts of things for all sorts of
>>reasons.
>>
>>Shann and a team reviewed the evidence for
>>reduction of neurological injury recent;y
>>(Shann J Thorac Cardiovasc Surg
>>2006;132:283-290). If we believe in evidence
>>based medicine than there are a few
>>recommendations to be looked at. However, TEE
>>for assessment of de-airing was not included.
>>Nor was CO2. Many of the studies used applied
>>only to CABG patients.
>>
>>
>>
>>
>>
>>
>>>But Roberto how are you certain it is TEE that
>>>made this difference? I have seen a similar
>>>argument made by protagonists of blood
>>>cardioplegia (that better preservation has all
>>>but eliminated post op VF). There have been
>>>numerous changes in cardiac surgery in the
>>>last decade so it would be difficult to
>>>ascribe an effect to any one change except if
>>>there is indirect or direct supporting
>>>evidence.
>>>
>>>Don't get me wrong though - I would not
>>>envisage surgery without TEE and use it myself
>>>to deair everyday, but like the axiom goes
>>>half of what we do at anytime is of no benefit
>>>and some even harmful - I do not know where
>>>TEE deairing lies and certainly evidence of
>>>its benefit is at best circumstantial. However
>>>on an individual level I take yours and Hal's
>>>perspective that we should strive to get all
>>>the air out by whatever means. As Hall said it
>>>is possible to conduct an operation in a way
>>>that you do not have air in the heart at the
>>>end and that is regardless of TEE. TEE is one
>>>factor but maybe there are many others.
>>>
>>>Ani
>>> ----- Original Message -----
>>> From: Dr. Roberto Battellini<mailto:battr at medizin.uni-leipzig.de>
>>> To: OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com>
>>> Sent: Saturday, March 03, 2007 7:32 AM
>>> Subject: AW: AW: [HSF] Deairing the heart
>>>
>>>
>>> Ani,
>>> I disagree.There is difference before and after TEE.
>>> Since we make all our valves under TEE, we have reduced significantly the
>>> number of patients we had to defibrillate
>>>soon after surgery. We let run the
>>> needle vent until there are no more bubbles. Of course, it is very
>>> sensitive.
>>> Roberto
>>>
>>> -----Ursprüngliche Nachricht-----
>>> Von:
>>>openheart-l-bounces at lists.hsforum.com<mailto:openheart-l-bounces at lists.hsforum.com>
>>> [mailto:openheart-l-bounces at lists.hsforum.com] Im Auftrag von Ani Anyanwu
>>> Gesendet: Freitag, 2. März 2007 14:10
>>> An: OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com>
>>> Betreff: Re: AW: [HSF] Deairing the heart
>>>
>>> But Hal I would question the relevance of subtle neurological changes that
>>> require a battery of sophisticated tests to demonstrate. A lot of these
>>> changes IMHO are integral to having artificial extracorporeal circulation
>>> and indeed MRI studies show changes in many patients with no neurological
>>> complications. Air and embolism are an integral part of CBP and in most
>>> cases are likely of no or of minimal consequence. Obviously though we must
>>> exclude gross air bubbles and our deairing approach, including CO2 and TEE
>>> is very similar to yours.
>>>
>>> However, I think to a great degree air is an invention of TEE and most of
>>> what we see on TEE or strive to achieve with TEE is of little relevance
>>> above that which can be determined
>>>clinically as in Novick's practice or in
>>> the practice of the 1980s. Like you I vent the root up to 15 mins after
>>> coming of bypass and I suspect in most patients this will be sufficient to
>>> deal with any rogue bubbles that failed deairing - regardless of the
>>> presence of TEE.
>>>
>>> I am not sure there is any direct evidence that the incidence of
>>> neurological complication or
>>>neuropsychometric deficit has changed with the
>>> advent of TEE or that the incidence is different in centers that routinely
>>> use TEE and centers that don't. Those surgeons in life courses who don't
>>> seem to deair properly may not necessarily
>>>be harming their patients. In my
>>> previous center (Harefield with Yacoub) we
>>>generally ignored the snowstorms
>>> seen on TEE and apparently (I know I know) to no consequence.
>>>
>>> Ani
>>>
>>>
>>> ----- Original Message -----
>>> From:
>>>Hgrmd at aol.com<mailto:Hgrmd at aol.com<mailto:Hgrmd at aol.com<mailto:Hgrmd at aol.com>>
>>> To:
>>>OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com>>
>>> Sent: Friday, March 02, 2007 7:33 AM
>>> Subject: Re: AW: [HSF] Deairing the heart
>>>
>>>
>>> Bill,
>>> I'm somewhat surprised that you don't use CO2, because it definitely
>>> does
>>> reduce or eliminate air emboli. Your
>>>stroke rate is laudible. However,
>>> I
>>> assume you are talking about fixed deficits only. Air emboli
>>>often
>>> present as
>>> a diffuse encephalopathy with no focal
>>>deficits. Unless you are having a
>>> battery of neurologic exams done on your postop patients, I wouldn't
>>> place too
>>> much credence in the amount of brain
>>>damage you currently think is being
>>> inflicted on your patients. As we all know in adult cardiac surgery,
>>> subtle
>>> permanent personality changes may be the only manifestation of
>>> perioperative
>>> neurologic injury. Those usually aren't factored into the postop stroke
>>> rate.
>>> Perhaps your kids would do better in the 1st grade if you
>>>considered
>>> adding this to
>>> your technique. I know that you can't
>>>really monitor its effect since I
>>> presume you don't have a TEE scope small
>>>enough to acommodate an infant.
>>> For
>>> your larger patients, I would definitely consider using a pediatric
>>> scope.
>>> Hal
>>>
>>><BR><BR><BR>**************************************<BR>
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>>
>>
>>--
>>Ben Bidstrup FRACS FRCSEd FEBCTS
>>Consultant Cardiothoracic Surgeon
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Ben Bidstrup FRACS FRCSEd FEBCTS
Consultant Cardiothoracic Surgeon
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